MH

After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?

"Are you currently thinking about harming yourself"

A frightened young woman calls the emergency department and tearfully tells the triage nurse, "I have been raped. Please help me!" Which nursing questions take priority?

"Are you injured, and are you in a safe place?"

A client who has major depressive disorder states to the nurse that he and his family would be better off if he was gone. Which of the following is the nurses priority response?"

"Are you thinking of harming yourself?"

A client tells the nurse that her brother just told her that he has inoperable pancreatic cancer. Which comment would show empathy by the nurse?

"How upsetting this must be for you?"

A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end, Easter. It blows away, get it?" Which of the following would be the best nursing response?

"I am having difficulty understanding what you are saying"

After her husband died of a heart failure a wife approaches the nursing care for her husband. In the hospital hallway the white shelves angrily he still be alive if you've given him your undivided attention which response should the nurse implement?

"I understand that you're upset. Let's find a quiet place to talk"

As a nurse escorts a client being discharged after treatment of major depression, the client gives the nurse a necklace with a heart and pendant that says, "Thank you for helping mend my broken heart". Which of the following is the nurse's best response?

"I'm glad I can help you bit I can't accept the gift. My reward is seeing you w/a renewed sense of hope"

Which statement made by the client during an initial assessment interview should serve as the nurses priority focus for the plan of care?

"I've been hearing voices of my dead parents"

A woman comes to an emergency department with a broken nose and multiples bruises after being beaten by her husband. She states, "The beating have been getting worse and I'm afraid that next time he might kill me" Which of the following is the appropriate nursing reply?

"Let's talk about your options for you to decide where to go"

Your client is very stressed about work and has started taking yoga classes. Which comment would indicate that this physical activity has been successful?

"My doctor says that my blood pressure has gone down"

A client says, "I have nobody anymore. I wish I could just die". Which response from the nurse would be considered non therapeutic?

"Oh, don't think about that. It's too depressing. You need to be focused on the good things".

Depressed depressed client discussing mental problems with the nurse says, " what will I do with my husband asked me for divorce?" which of the following response by the nurse will be an example of a therapeutic communication?

"What has happened to make you think that your husband will ask for a divorce?"

A client who is delirious yells out to the nurse, "You're an idiot. Get me your supervisor". Which is the best nursing response in this situation?

"You're going through a difficult time. I'll stay with you"

While working with family members of a dying client, which intervention should the nurse include in the plan of care?

-Encourage the family to express emotions freely -Provide information and answer any questions related to the care of this person

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse to recognize that which of the following medications are used to treat clients who have bipolar disorder?

-Lithium -Valporic Acid -Lammotrigine

Which interventions should a nurse utilize were caring for in inpatient client who expresses anger in appropriately?

-Maintain a calm demeanor -Set limits on behavior -Clearly delineate consequences of behavior

Mrs. J has a history of pernicious anemia and visits her physicians office bi monthly for vitamin B12 injections. Order: vitamin B12 0.5 mg IM bi monthly. Supply: Vitamin B12 1000 mcg/mL How many mL of vitamin B12 will Mrs. J be receiving with each dose?

0.5

A client has ordered triazolam 0.625 mg PO for insomnia. On hand is triazolam 0.25 mg tablets. How many tablets will the nurse administer with each dose? (Type the number only, do not include the label. Please answer to the tenth, or one decimal place. Use the leading zero if it applies. (Do not use a trailing zero)

2.5

The nurse is caring for a client who is prescribed haloperidol 4 mg orally on admission. An oral suspension of haloperidol 2mg/mL is received from the pharmacy. What amount of the oral suspension should the nurse administer to the client?

2mL

The client is in a crisis state following an environmental disaster. At the beginning of the initial assessment interview, what should the nurse assist the client to identify?

??

A nurse is caring for a group of older adult client. Which of the following manifestations indicates one of the clients is experiencing delirium?

A client attempts to climb out of bed and repeatedly states she must go home

A nurse is reviewing The medical histories of four clients. Which of the following clients may develop extra pyramid middle symptoms from medication therapy?

A client who has schizophrenia and its taking antipsychotic medication

Which neurotransmitter has been implicated in the development of Alzheimers disease?

Acetylcholine

The nurse understands that, following a crisis, a client may function better than before the crisis. Which of the following shows the client managing through a crisis>

Acquiring and strengthening coping skills

Which finding indicate successful completion of an individual's grief and morning?

After 15 months, a widower realistically remembers both pleasures and disappointments of his relationship with his wife

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

Amenorrhea

A child was adducted and raped. In the emergency department, the client is crying uncontrollably. Which personal reaction by the nurse could interfere with the clients care?

Anger

A client on a psychiatric unit says, " it's a waste of time to be here. I can't talk to you or anyone". Which will be an appropriate therapeutic Nursing response?

Are you feeling that nobody understands?

A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following actions should the nurse take?

Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

Which of the following is a therapeutic communication strategy do use with a client who has auditory hallucinations?

Asking the client to describe his hallucinations

A client diagnosed with dementia wanders the halls of a nursing unit during the day. Which of the following would the nurse do first ti ensure safe care is implemented?

Assess client gait for steadiness

Which nursing intervention has highest priority for a client with bulimia response?

Assist the client to identify triggers to binge eating

A nurse is caring for a client who has an eating disorder. The nurse is practicing which of the following ethical concepts when the client refuses to drink a nutritional supplement in between meals?

Autonomy

Which of the following interventions best demonstrates what a nurse can do to provide structure with a client who has a personal disorder and is making constant demands of staff

Be consistent in response to client demands

A highly emotional client presents at an outpatient appointment wearing flamboyant attire, spiked heels and theatrical makeup. Which personality disorder should a nurse associate with this behavior?

Borderline personality

How should a nurse prioritize nursing diagnosis Within our clients plan of care?

By life threatening potential

A client diagnosed with bipolar disorder in the maniac phase is yelling at another peer in the common area. Which nursing intervention takes priority?

Calmly redirect and remove the client from the common area

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations which of the following hallucinations is the priority for the nurse to address?

Command

A client has been receiving oxycodone for moderate pain. The client has returned to the clinic three times for refills of the prescription. What assessment by the nurse in addition to slurred speech, leads the nurse to suspect opioid intoxication?

Constricted pupils

A nurse is assessing a client who has a new diagnosis of bulimia nervosa. Which of the following findings should the nurse expect?

Dental erosion

Which of the following co morbid conditions is associated with anorexia nervosa?

Depression

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessmrnts by the nurse is the priority?

Determine the clients current level of anxiety

An 80-year-old female client arrives at the emergency department with her son and daughter-in-law,With whom she lives. She is found to have a broken arm. Her son and daughter-in-law seem very agitated with a client. One question about how it happened and she drops her hair remember that she doesn't really know. Given the client reaction, the nurses facts which of the following possibilities?

Domestic Violence

A nurse is planning to administer haloperidol to a client who has acute psychosis. The nurse should monitor the client for which of the following findings as an adverse effect of the medication?

Dystonia

Family members of an alcoholic client asks the nurse to help them intervene. Which action is essential for a successful intervention?

Each family member must tell how the addiction has affected them

A nurse is assessing a client with schizophrenia who has been taking risperidone for one year the nurse notices that the client has grimacing and find tongue movement. What do the symptoms most likely indicate?

Early symptoms of Tardive Dyskinesia

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is having trouble sleeping. Which of the following actions should the nurse take?

Explain that antidepressants often take several weeks to be fully effective

After the death of a spouse, an adult repeatedly says, " I should have made him go to the doctor when he said he didn't feel well". The nurse understands this individual is experiencing which of the following responses to grief?

Guilt

A client with acute mania has exhausted the staff by noon. The client has joked, manipulated, insulted, and argued all morning. Staff members are feeling defensive and fatigued. Which is the best action?

Hold a staff meeting to discuss consistency and limited setting approaches

A nurse assesses a client who reports a three week history of depression and crying spells the client says, "My business is bankrupt, and I will serve with divorce papers" which statement by the client alert the nurse were hidden suicidal message?

I have a plan that will fix everything

A nurse and a mental health care facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrate an appropriate response when dealing with manipulative behaviors?

I understand you are angry. However, the consequences of the negative behavior have been discussed with you"

Which of the following would be appropriate criteria for hospital admission of a person diagnosed with anorexia nervosa?

Inability to gain weight with outpatient treatment

The client with major depressive disorder taking a selective serotonin reuptake inhibitor call psychiatric clinic and reports feeling confused and restless and having an elevated temperature. Which actions to the psychiatric nurse take?

Instruct the client to stop taking the SSRI and come in for further investigations

A nurse is caring for a young adult client who says he is experiencing increased anxiety in an inability to concentrate. Which of the following will be the most appropriate for the nurse to make?

It sounds like you're having a difficult time

A nurse is assessing a parent who lost a 12-year-old child in a car crash two years ago. Which of the following findings indicate the client may be exhibiting maladaptive grieving?

Leaves the childs room exactly as it was before loss

A young mother in a severely abusive relationship is it made it to the psychiatric unit after an attempted suicide. The client tells the nurse, " I am sure things will be fine between us when I get home". What is the most appropriate response for the nurse to make?

Let's develop a safety plan in case he becomes violent again

A client on an impatient psychiatric unit is experiencing a flashback. Which interventions takes priority?

Maintain and reassure the client his or her safety and security

Client client has been taking risperidone for a few months and is exhibiting the signs and symptoms upon admission: High fever, muscle rigidity, tachycardia, and a decreased level of consciousness. Which adverse effect of antipsychotics to the symptoms best describe?

Neuroleptic malignant syndrome

The nurses working with a client who was preoccupied with perfection, cannot this car anything and have trouble relaxing. Which of the following personality disorders are being described with this example?

OCD

A nurse is caring for a client who states, " I have to get out of this hospital they found my address and are coming from my family!" The nurse responds, " don't worry no one will come for your family". Which of the following types of communication breakdown does this response represent?

Offering false reassurance

A client with delusions of persecution and being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the client?

Offering food choices in sealed packaging or containers

Psychiatrist prescribed phenelzine for a client. Which foods should the nurse teach the client to avoid?

Pepperoni Pizza and red wine

One question about bruises, a woman states, " it was an accident. My husband had a bad day at work. He's being so great now and even bought me flowers. He's going to get a new job and it won't happen again". Which phase of the cycle of battering is this client?

Phase III: The honey moon phase

A nurse asks a client how he is feeling. The client states, "I'm a bit nervous today". Which of the following responses should the nurse make?

Please explain what you mean by the word "nervous"

The nurse is caring for a client who attempted suicide and it's being closely monitored for potential safety health serious. Which of the following rights has the patient loss?

Privacy

A nurse at a college campus mental health counseling center is caring for a student who just failed in a examination. The student spent the session complaining about the instructor in the course. The nurse should recognize behavior is which of the following defense mechanisms?

Projection

A client is diagnosed with late stage alzheimers dementia. To address the clients symptoms, which nursing intervention should take priority?

Promote dignity by providing comfort, safety, and self care measures

The nurse is caring for a client with Alzheimer's dementia on the long-term care unit. Which of the following will be an essential nursing intervention for this client?

Provide a daily routine with reminders signs and large face clocks

The nurse is providing care for a client who was recently diagnosed with major depression. The nurse realize which of the following is a priority for the care of this client?

Providing a safe environment

a nurse in an inpatient mental health unit who has panic level anxiety. After showing the client to his room, which of the following nursing actions is the most therapeutic?

Remain with the client for a while

A psychiatric home health nurse has just received an order to begin regular insulin visits to a 79 year old widow with mild dementia who lives alone and has a new diagnosis of depression. Based on a needs assessment, which of the following problems would the nurse address during the first visit?

Risk for injury

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

Risk for injury R/T delirium

Which of the following drugs is prescribed for treatment of Alzheimers dementia?

Rivastigmine

According to Maslow's hierarchy of needs. Which of the following needs set the nurse address first?

Safety

A widow grieving her husband sudden and unexpected death sells the nurse, " i'm not feeling well. Yesterday, I saw my husband walk through the door, stop, and smile at me. Then he just faded away". which response by the nurse reflects on understanding of the clients experience?

Seeing a recently deceased loved one is a normal part of the grieving process

A nurse in the emergency department is assessing a client who has experienced partner abuse. The nurse should monitor which of the following behavioral findings?

Self esteem disturbance

A nurse in a mental health facility is planning care for a client who has obsessive compulsive disorder (0CD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the clients compulsive behavior?

Set strict limits on the behaviors so that the client can conform to the unit rules and schedules

A nurse is working with the client with a histrionic Personality disorder and another client with a narcissistic personality disorder. For both of these clients, which nursing intervention must be a high priority throughout the inpatient stay?

Setting appropriate limits

Which of the following actions best describes a nurse who is acting as a role model for advocacy for the mentally ill?

States, "I wish you would not insult people with mental illnesses"

What is a nurses most appropriate action when a client is seen openly masturbating in the recreation room?

Stating that the behavior is unacceptable and directing the patient to a private area.

Which of the following best described an example of providing primary prevention for domestic violence intervention?

Teaching a class for new families about how to cope with life stressors

A nurse is caring for a hospitalized client who is bipolar and and will be discharged on lithium. Which of the following situations would most likely place the client at risk for developing lithium toxicity?

The client has an illness that causes diarrhea

A nurse is observing a clients non verbal behavior. When evaluating this behavior. The nurse should factor in which of the following principles of non verbal communication?

The clients sociocultural background influences non verbal communication

The clients family is raving following his recent death. Which action by the nurse offers the most comfort to the family?

The nurse tells the family, "I care"

A client is involuntary admitted to a psychiatric unit after calling a friend and saying, " i've got a gun and I'm going to shoot myself". Which of the following rights has the client lost temporarily

The right to leave hospital without medical approval

When planning care for a client diagnosed with borderline personality disorder, which self harm behavior should a nurse expect a client to exhibit?

The use of suicidal gestures to elicit a rescue response from others

A nurse is providing medication teaching for a client who has a new prescription for clozapine. Which of the following statement indicates a need for further teaching?

This medication will help prevent seizures

A client drowned went swimming in a lake two years ago. Which behavior Bethany case the clients parents are morning in an effective way?

Throw flowers on the lake at each anniversary date of the accident

Which individual with a mental illness may require emergency involuntary hospitalization?

Throws a heavy plate at a waiter at the direction of command hallucinations

A nurse is in a crisis hotline speaking speaking to a client who says, " I just refilled my script and took in entire bottle of amitriptyline". The nurse sends immediate medical attention due to which of the following reasons?

Tricyclic antidepressants are known to be fatal in overdose

Which of the following potential physical complications are most likely to develop in the alcohol dependent person? Select all that apply

Urinary retention, pancreatitis, cirrhosis, and Korkassofs psychosis??

You are working with a client who has been admitted with generalized anxiety disorder. The client tells you she knows she is dying and no one will tell her. She paces constantly and wrings her hands. Which of the following interventions will most likely be included in her plan of care?

Use a calm approach, encourage her to talk about what feelings she is having

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact

The nurse in a detoxification unit received a phone call from a person who identify as himself as a newly admitted clients employer. He asks, "Did he fall off the wagon again?" which of the following by the nurse will be the most appropriate response?

We are unable to provide that information.

The client admitted to the psychiatric unit diagnosed with schizophrenia is prescribed clozapine, a second generation antipsychotic. Which of the clients laboratory data should the nurse evaluate?

White blood cell count

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out". Which of the following would be the most appropriate response for the nurse to make?

You feel that you don't belong here?

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurses station at 0300, demanding the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

You must be very upset about something

Which is the best nursing action when a client demonstrates transference toward a nurse?

by helping the patient clarify the meaning of the nurse-client relationship, based on the present situation.

The nurse may choose to include complimentary therapies in the care plan for a client with mental illness. Which of the following are examples of complementary examples?

guided therapy and physical therapy???